Microsoft word - mini-ivf

MINI-IVF
Low stimulation IVF protocols are nothing new. Clomid based medication protocols have been around for decades. With the advent of injectable medications many years ago, Clomid based cycles were largely abandoned. This is due to the overall poorer success rates with low stimulation type protocols - especially Clomid based protocols. There is unfortunately a strong misconception that somehow, taking such medications makes a “bad egg” good, and somehow improves egg quality in the context of IVF. While this may sound appealing, it is flatly and simply untrue. With low stimulation type protocols, wherein less medication is undertaken to ostensibly save costs, the obvious and logical reaction will be to produce fewer follicles and eggs. This will unquestionably have an impact on the probability of IVF success in any given cycle. However, the cumulative pregnancy rate might be reasonable with such protocols. That is to say, a patient undergoing three mini-IVF cycles could expect to retrieve an equivalent number of eggs to a patient undergoing one traditional full-stimulation IVF cycle. Thus, the cumulative pregnancy potential would be comparable between the two patients having a similar total number of eggs. There are of course downsides to the mini-IVF concept that need to be looked at and discussed. There is the blatantly lower per-cycle IVF success potential, necessitating the multiple cycle concept. There is nothing wrong with this, of course, and patients need to be aware that the multi-cycle approach is what is required. Thus, the idea that there is a cost savings with mini-IVF is tempered significantly when this is factored into the equation. It is similar with insemination cycles as an alternative to IVF. Insemination also has a very low pregnancy potential per cycle. That is not to say it is a bad treatment per se, but one would expect to undergo three or four IUI type treatments prior to considering moving forward to IVF. It is a similar mentality when considering mini-IVF cycles versus traditional stimulation. Certainly, patients who have the inherent ovarian function and “ability” to produce multiple follicles and eggs are generally better served on a per-cycle success rate basis to undergo traditional stimulation IVF. Of course, one should exercise reason in these protocols to not excessively stimulate the ovaries if possible. This has ultimately diminishing returns. That is, there is clearly a benefit in per-cycle success potential when one achieves a good number of eggs with these medications. However, beyond a certain number of eggs, it does not necessarily translate into improved probability. There is a plateau effect in ovarian stimulation. Cost factors go into any individual couple’s point of optimal benefit. These factors need to be considered on an individual basis. Thus, the “cookbook” method of low stim and mini-IVF type protocols has its place and should be considered by some couples for several reasons, not just financial. Factoring the good and bad points of these various cycle options needs to be looked at and considered.
Ultimately the couple should be able to determine the best option with respect to their personal circumstances (finances, ethical beliefs, family dynamics, etc.). It is the physician’s responsibility to present these options in a neutral and factual manner, assisting in the ultimate decision making as the couple might request. That said, educating patients and couples with respect to their own circumstances and through the prism of their own individual case is always the rule -- offering these options, discussing and educating the couple with respect to their own personal circumstances and medical issues, and ultimately helping them make the decision that is best for them. In most cases, they will take the medical information and advice offered by us, consider the various personal factors, and ultimately decide on what they feel is the best option. This is the approach that I advocate very strongly. We have the ability at our center to offer any type of stimulation protocol, but we strongly disagree with the cookbook approach, the “one size fits all” approach, and the blanket application of low stimulation protocols in situations wherein it is not necessarily medically optimal for patients with respect to outcome.

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